NEW CLIENT INTAKE FORMFill out information to your best ability Please Select New Client Existing Client Name * First Name Last Name Email * Phone # * (###) ### #### Date of Birth / Age Occupation # Of Children Relationship Status Do you have symptoms / complaints in any of the areas listed? Check all that apply Neck Ears Eyes Jaw Problems Back - Upper Back - Middle Back - Lower Heart Conditions / Arrhythmia Hips Knees Ankles Feet Hands / Fingers Nails - Nail Biting Wrists Arms Elbows Shoulders Indigestion / Heartburn / Ulcers Stomach / Digestion Issues Constipation Menstrual / Female Area Problems Menopause Problems Endometriosis PCOS Bladder Problems Migraines Headaches Skin Problems Blood Pressure - High Blood Pressure - Low Thyroid Problems Insomnia Fatigue Arthritis Rheumatoid Arthritis Fibromyalgia Carpal - Tunnel Syndrome Sciatica Vertigo / Dizziness Weight Problems Diabetes Sinus Problems Asthma Allergies - Outdoors Allergies - Food Cancer Concern #1 Concern #1: When did symptoms begin? Concern #1: Did any event / accident take place durning that time? Note: We will discuss this further in our session. Ex. Relationship ended. Loss of family member. Car accident. Injury. Job change. A move. Etc. Concern #2 Concern #2: When did symptoms begin? Concern #2: Did any event / accident take place durning that time? Note: We will discuss this further in our session. Ex. Relationship ended. Loss of family member. Car accident. Injury. Job change. A move. Etc. Additional Areas Of Concern: Location / Description / Frequency Do you have a medical diagnosis? List all conditions: List any surgeries you have had and estimated year: Write NA if none Are you working with any other practitioner for your symptoms? Medical Doctor Physical Therapist Chiropractor Massage Therapist Acupuncturist Naturopathic Doctor Counselor / Therapist Other Can you identify any emotions or feelings that are affecting your daily life? Check all that apply: Anger Irritability Depression Grief / Loss Sadness Anxiety Burn Out / Exhausted Unmotivated Resentment Family Stress Relationship Stress Work Stress Fear of Future Other - Use box below Provide any additional emotions or feelings you would like to share: PLEASE NOTE: In our session we will address 1 concern to begin. A follow-up session may be needed to continue addressing the concern and/or any additional concerns you have listed. We will address your next concern if time allows. What concern would you like to address in our first session? If there is time what is the second concern would you like to address in our session ? Disclaimer * I am fully aware and agree that this session is not to diagnose any physical and/or mental condition(s). It is not meant to replace professional medical advice. Any techniques used are not a sole form of treatment for physical and/or medical problems. The intent for this session is to provide information to help in the healing process for your emotional and spiritual wellbeing. Yes No Prior to Session - Introduction Video You will receive a link to an introduction video (5-7 min) prior to your session. This video will provide valuable information including: About myself and work / Flow of session / Introduction to practices we will use in our session. *If I am unable or do not watch video prior to session I am aware that this information will be addressed at the beginning of our session and the time will be deducted from the session. I AGREE to watch video prior to session Prior to Session - Additional Information Once your intake form is received I may reach out prior to your session via email or phone/text for additional information/clarification to better maximize and prepare for our session together. Scheduling Your Session What times and days work best for you? Select ALL that apply I will be in contact via email or text within 24 hours to schedule your session. Monday - morning Monday - evening Tuesday - morning Tuesday - evening Wednesday - morning Wednesday - evening Thursday - morning Thursday - evening Friday - morning Friday - evening Saturday - mid morning Sunday - mid morning Thank you for filling this intake form out. I look forward to our session together. Your intake form as been submitted. I look forward to our upcoming session together.
